Bilateral Dissection Research Articles

Spontaneous Renal Artery Dissection in COVID-19 Pneumonia: Potential Danger of Cytokine Storm

The coronavirus disease (COVID-19) pandemic has rapidly spread across the globe since its first detection in March 2020. Its widespread manifestations and vascular complications are increasingly being reported even in young and middle-aged patients. Hyperinflammation is a continuum of host's exaggerated inflammatory response representing cytokine dysregulation/storm which produces coagulopathy and vascular endothelial dysfunction, apart from a prothrombotic state. Cytokine storm or direct viral invasion of the vascular endothelial cells through surface angiotensin-converting enzyme 2 receptors may result in endothelial dysfunction which can potentially result in dissection. Only a few case reports have been published in the literature describing vascular dissection without any inciting factors in COVID-19 patients. Herein, we present the first case report of bilateral renal artery dissection in a 41-year-old male patient who recently recovered from COVID-19 and was managed successfully in stages after many medical hurdles.

Endovascular treatment of bilateral spontaneous dissection of common iliac artery involvement of the aorta and 3-year follow-up results

Spontaneous dissection of the iliac artery is very rare. We report the case of a 49-year-old man who presented with spontaneous dissection of common iliac artery involvement of the aorta. We treated him by unibody bifurcated stent grafting and deployed the second stent-graft to prevent the collapse of the true lumen of the right iliac artery. For the sake of preserving pelvic blood flow, proximal type I endoleak was not treated. After 3 years, the endoleak still existed, without any aneurysmal formation. Further, the dissection of the distal external iliac artery still existence after 3 months, but the virtual disappearance after 3 years.

A Malignant Melanoma of the Penile : A Very Rare Case Report and Literature Review

Background: Malignant melanoma of the penis is very rare, accounting for approximately 1.4% of all primary penile carcinomas. With a small prevalence of penile melanoma, there is lack of data about quality of the therapy. The primary treatment of melanoma of the penile is surgical, although there is a lack of consensus regarding the extent of treatment that is indicated.
 Case Report: A 60-year-old Caucasian man came to Division of Urology, Department of Surgery, Dr. Kariadi General Hospital Semarang with chief complaint painless and fast growing lesions on his penile. His general condition was fine, and has a normal vital signs. On the physical examination of penile region, there were found lesions on the ventral of the glans and penile foreskin and covered with blood and pus, with bilateral inguinal lymph nodes and lung metastasis from Multi Slice Computed Tomography. We already performed partial penectomy and bilateral inguinal lymph nodes dissection with histopathological results a malignant melanoma Clark IV. The final stage of penile melanoma was pT2N1M1. We follow-up the patient until 1 year after procedure, and there wasn’t any recurrence.
 Conclusion: Malignant melanoma of the penis is rare. Penile melanoma is highly treatable with surgical excision in its early stages because of resistant to both chemotherapy and radiotherapy. Delay in diagnosed and surgical treatment can lead to an adverse prognosis. The anamnesis, physical examination, and imaging studies must be done appropriately to improve the survival.

Endometrial stromal sarcoma- A case report

Endometrial stromal sarcomas are rare malignant tumours of the uterus. Most details about this tumour is obtained from previous case reports. In most of the cases, diagnosis is made only postoperatively. A 29 year old female, came with complaints of heavy menstrual bleeding, lower abdominal pain, mass in lower abdomen for 2 months. Clinical examination and investigations showed bulky irregularly enlarged uterus probably Fibroid Uterus. Patient was planned for Myomectomy. Intraoperatively, uterus was irregularly enlarged with cauliflower like growth of size 7 x 5 cm over fundus suggestive of Carcinoma. Total abdominal hysterectomy with bilateral salphingo oophorectomy with bilateral pelvic lymphnode dissection with infracolic omentectomy was done. Histopatholgy examination revealed as Low Grade Endometrial Stromal Sarcoma with Negative Lymph Node Spread. Postoperatively, Patient was evaluated for ER sensitivity and started on Tab. Anastrazole. Keywords: Uterine sarcoma, Endometrial stromal sarcoma, Malignant uterine tumour.

Log ODDS (LODDS) of positive lymph nodes as a predictor of overall survival in squamous cell carcinoma of the penis.

To evaluate the role of logarithmic ODDS (LODDS) in the number of positive lymph nodes and the number of negative lymph nodes as a prognostic metric in the squamous cell carcinoma (SCC) penis. Data were retrospectively collected from 96 cases of SCC penis that underwent bilateral groin dissection between 2010 and 2015 at our institute. Lymph node density (LND) and LODDS were calculated for all the patients and classified according to American Joint Committee on Cancer (AJCC) pN staging. Thresholds for LND (24% and 46%) and LODDS (-0.75 and 0) were established. Multivariate analysis of various cofactors was done with overall survival (OS) as a dependent factor. Three classification systems were compared using receiver operative characteristic (ROC) curve analysis. Univariate analysis showed that AJCC pN, LND, and LODDS were all significantly correlated with OS. However, only LODDS (HR, 11.185; p = .023) remained an independent prognostic factor through multivariate analysis. LODDS (log-likelihood = 3832 vs. 3798; p < .001) had better prognostic performance than pN and better discriminatory ability than LND (AIC = 3902 vs. 3928). LODDS had better power of discrimination than LND and pN. LODDS could predict survival in lymph node yield (LNY) < 15 (p < .001). LODDS is an independent predictor of OS in the SCC penis and has superior prognostic significance than the AJCC pN and LND classification systems.

A Prospective Study of Vitamin D Supplement in Thyroidectomy Patients Based on Relative Decline of Parathyroid Hormone.

Background: In postthyroidectomy patients, hypocalcemia is the most common complication to prolong hospital stay and decrease patients’ satisfaction. Based on current evidence, it is recommended to supply vitamin D to patients with high risk of developing hypocalcemia. However, how to stratify the risk of patients remains challenging. Aim: We conducted a prospective study to evaluate the effect of vitamin D supplement (calcitriol) on high-risk hypocalcemia patients based on relative decline of parathyroid hormone (RDP). Method: RDP was calculated by the difference between preoperative and postoperative first-day PTH divided by preoperative PTH and presented as percentage. Patients who underwent total thyroidectomy in addition to bilateral central compartment dissection were enrolled prospectively and were divided into two cohorts: Cohort I: patients with RDP ≤70% and Cohort II: patients with RDP >70%. Patients in Cohort I were then randomly assigned to Group A or B, and patients in Cohort II were randomly assigned to Group C or D. All groups received oral calcium, and patients in Groups B and D also received calcitriol. All patients were followed for one year. In the study, standard procedure dictates that only oral calcium is given to patients whose RDP ≤70% and that oral calcium and calcitriol are given to patients whose RDP >70%. Therefore, Cohort I Group A and Cohort II Group D are controls in this study. Results: The incidence of clinical hypocalcemia in Groups A and D (the controls) was 11.0% (10/91), and 17.6% (16/91) required additional intravenous calcium. Of note, no patients developed permanent hypocalcemia. Furthermore, calcitriol supplement did not have significant impact on clinical outcomes between Group A and B in Cohort I. By contrast, calcitriol supplement distinctly improved clinical outcome by comparing Groups C and D (Cohort II), as marked by clinical hypocalcemia, need of requiring intravenous calcium, and long-termed decreased levels of PTH. Conclusion: Supplying calcitriol based on RDP cutoff of 70% may be a wise practice in thyroidectomy patients, and RDP 70% may be a useful predictor to stratify high-risk patients.

Unilateral or Bilateral Retroperitoneal Lymph Node Dissection in Nonseminoma Patients with Postchemotherapy Residual Tumour? Results from RETROP, a Population-based Mapping Study by the Swedish Norwegian Testicular Cancer Group

BackgroundThe distribution of retroperitoneal lymph node metastases for patients with nonseminoma and a residual tumour of 10–49 mm in a population-based setting is unknown. This information is needed to justify selection of patients for a unilateral template resection. ObjectiveTo describe the location of retroperitoneal metastases and recurrences in patients with nonseminoma germ cell tumour (NSGCT) with a residual tumour of 10–49 mm. Design, setting, and participantsRETROP is a population-based prospective observational mapping study of 213 patients in Sweden and Norway with a retroperitoneal residual tumour of 10–49 mm who underwent postchemotherapy retroperitoneal lymph node dissection for metastatic NSGCT during 2007–2014 with median follow-up of 100 mo. Patients were classified according to the testis primary tumour and the distribution of unilateral or bilateral lymph node metastases (with reference to the aorta) present on pre- and/or postchemotherapy computed tomography (CT) scans. Outcome measurements and statistical analysisThe distribution and rate of teratoma or cancer in unilateral or bilateral retroperitoneal fields and the location and rate of retroperitoneal recurrence were measured. Results and limitationsIn total, 65% of the patients had unilateral retroperitoneal lymph node metastases (RLNMs) on CT scans. Patients with unilateral RLNMs had a low risk of contralateral teratoma or cancer (1.6% for right- and 2.6% for left-sided NSGCT) or retroperitoneal recurrence (0% for right- and 4% for left-sided NSGCT). A weakness of the study is that the pathology specimen could not be fully designated to one specific area for some of the patients. ConclusionsMen with postchemotherapy residual disease of 10–49 mm and unilateral metastases on pre- and postchemotherapy CT scans have a low risk of contralateral disease and should be considered for a unilateral template resection. Patient summaryThe surgeon can use computed tomography (CT) scans in deciding on the extent of lymph node dissection in patients with testicular cancer.

Indications for lateral lymph node dissection in patients with rectal neuroendocrine tumors: A case report and review of the literature.

The optimal surgical indications for small rectal neuroendocrine tumors (NETs) are controversial. Generally, treatment guidelines for rectal NETs >2 cm or with potential lymph node (LN) metastasis recommend formal oncologic low anterior resection (LAR) with total mesorectal excision (TME). However, rectal NETs have the potential to metastasize to the lateral lymph nodes (LLNs). To the best of our knowledge, there are no detailed reports in English on LLN metastasis from rectal NETs. A 47-year-old man diagnosed with a rectal NET underwent endoscopic submucosal dissection (ESD). The pathological diagnosis was NET G1. The tumor was 10 mm in diameter, and the tumor depth reached the submucosal layer. A period of 3 years after ESD, the patient was diagnosed with LN metastasis in the mesorectum and LLN metastasis on the left side from the NET. Robotic TME and bilateral LN dissection were performed. The pathological findings indicated that two of the 18 LNs in the mesorectum were metastatic, and all the LLNs on the left side were negative. In contrast, 1 of the 6 LLNs on the right side was metastatic. Early-stage rectal NETs can metastasize to the LLNs, and it is very difficult to detect LLN metastasis based on size alone. TME alone may be insufficient to treat rectal NETs, and additional LLN dissection may be an important treatment strategy. However, it is increasingly difficult to determine the surgical indications for optimally timed LLN dissection.

Young Male with Bilateral ICA Dissection: Beyond CADISS Trial

Objective: To report a case of young male with stroke and bilateral internal carotid artery (ICA) dissection. Background: Cervical Artery Dissection in Stroke Study trial has provided some insight on management of patients with ICA dissection. However, there is a need to modify the management strategies as per specific clinical scenario. Design/Methods: Case report and literature review. Results: A 45-year-old male presented with 1 month old history of acute onset numbness of right half of the body with slurring of speech. Computed tomography angiography showed complete occlusion of left cervical ICA just beyond origin with presence of fusiform dilatation and spiral flap in right extracranial cervical ICA. The patient was started on antiplatelets and taken for endovascular procedure using 2-mesh-based carotid stents. Patient was discharged after 3 days on antiplatelet therapy. At 1-year follow-up, there were no fresh symptoms. Conclusion: This case emphasizes the role of successful endovascular management of carotid dissection in a young male. These clinical situations may not be fully represented in trials, and a case-based approach is required.

Urethral cancer managed with phallus preserving surgery: a case report

BackgroundPrimary urethral carcinoma (PUC) is rare and accounts for < 1% of all genito-urinary cancers. There is a male predominance of 3:1 and a peak incidence in the 7th and 8th decades. The aetiology of this cancer is similar to penile cancer, and the human papilloma virus (HPV) is thought to be an essential factor in tumorigenesis. Urethral cancer should be diagnosed and staged with a combination of tumour biopsy, MRI, and CT with treatment involving a multimodal approach. Contemporary management emphasises phallus-preserving surgery where feasible.Case presentationHere, we describe a case of distal urethral carcinoma, which presented as a metastatic groin mass and identifying the primary lesion proved challenging. Diagnostic flexible cystoscopy identified a tiny lesion in the navicular fossa, which was biopsied and confirmed to be a squamous cell carcinoma. The patient then underwent phallus preserving surgery, including distal urethrectomy with bilateral inguinal lymph node dissections. The final stage was pT1N1M0, and adjuvant chemotherapy was started. The distal urethrectomy involved the surgical creation of a hypospadic meatus in the midshaft of the penis. Normal voiding and sexual function were preserved.ConclusionsUrethral cancer is a rare malignancy and clinicians should bear in mind that early diagnosis of this disease can be very difficult depending on the anatomical location of the tumour. Treatment currently favours penis-preserving surgery.

Can Styloid Process and Internal Carotid Artery Anatomy be Used to Predict Carotid Artery Dissection?

Carotid artery dissection is a common cause of stroke in the young. It has been related to the association of the carotid artery with fixed neighboring anatomical structures. This study assesses the association between styloid process length, internal carotid artery position and cervical carotid artery dissection (CCAD). This information would provide potential predicative radiological measurements, which could prevent delays in CCAD diagnosis. Retrospective data was collected from 2 central London hospitals over 5 years. CCAD cases were identified from individuals who underwent computer topography angiography of the neck for suspected CCAD. The following data was collected: evidence of CCAD; bilateral styloid process length and presence of styloid-hyoid ligament calcification; bilateral styloid process-internal carotid distance; calcification of carotid arteries and whether their position was aberrant. Cases were dissection-side, age and gender matched with two non-dissection controls. Three hundred and fifty-five individuals were identified. Fifty individuals had CCAD, of which 4 had bilateral dissection. In individuals with CCAD, average styloid process length was 27.5 mm and styloid process-internal carotid distance was 5.14 mm. There was no significant association between styloid process length or styloid process-internal carotid distance, and CCAD when compared with matched controls. Internal carotid artery aberrancy was significant for nondissection. In this study, there was no association between styloid process length and styloid process-internal carotid distance with CCAD. These measurements can not be used to predict the possibility of a CCAD following trauma.

Clinical Analysis of 76 Cases of Differentiated Thyroid Isthmic Carcinoma after Operation

Objective: To investigate the clinicopathological features and surgical treatment of differentiated thyroid isthmus carcinoma. Methods: The clinical data of 76 patients with differentiated thyroid isthmus cancer diagnosed and operated in our hospital from January 2015 to January 2019 were retrospectively analyzed. Results: 16 cases of single focus, 60 cases with unilateral or bilateral multiple lesions, 76 patients. Bilateral thyroidectomy and bilateral CLN dissection were performed in 57 cases, unilateral thyroidectomy plus isthmus resection plus lateral total resection and bilateral central lymph node dissection in 17 cases. 2 cases underwent bilateral thyroidectomy plus bilateral CLN dissection plus unilateral neck lateral lymph node dissection. Lymph node metastasis occurred in 42 cases and lymph node metastasis in 40 cases, including 16 cases of unilateral central lymph node metastasis, 24 cases of bilateral central lymph node metastasis, and 2 cases with lateral cervical lymph node metastasis. 16 cases of single isthmus thyroid cancer, unilateral CLNM in 7 cases (43.75%), bilateral CLNM in 4 cases (25%), no metastasis in 5 cases (31.25%), and no lateral lymph node metastasis. Hypocalcemia occurred in 7 cases and temporary hoarseness occurred in 3 cases, which returned to normal within 3 - 6 months. All 76 patients were followed up. No permanent hypoparathyroidism, cervical lymph node recurrence, distant metastasis or death occurred in all patients. Conclusion: The treatment of differentiated thyroid isthmic carcinoma should be based on the pathological diagnosis, with bilateral thyroidectomy and bilateral CLN dissection as the main treatment. For patients with single focus, diameter ≤ 1 cm and low-risk group, if the above reasons are excluded, isthmus + unilateral gland resection and bilateral central lymph node dissection are feasible.

Suboccipital craniectomy with bilateral cerebellomedullary fissure dissection for resection of a ruptured tonsillar/vermian AVM occupying the roof of the fourth ventricle in a pregnant patient.

Posterior fossa arteriovenous malformations (AVMs) in pregnant patients can present unique considerations for surgical treatment, including positioning to minimize pressure on the fetus, minimization of radiation exposure, and ethical considerations regarding emergency surgery. This video outlines surgical treatment of a ruptured tonsillar/vermian AVM performed in a staged fashion after emergent suboccipital craniotomy with posterior fossa decompression in the setting of a life-threatening infratentorial hemorrhage. Later, bilateral cerebellomedullary fissure dissection, exposure and dissection of the tela choroidea and inferior medullary velum, and disconnection of arterial feeders from the posterior inferior cerebellar artery (PICA) allowed resection of this AVM occupying the roof of the fourth ventricle.This study was approved by the UCSF Human Research Protection Program IRB no. 18-26938.The video can be found here: https://youtu.be/rTYUGanopUE

Bilateral vertebral artery dissection after hair washing in a young woman

Bilateral vertebral artery dissection after hair washing in a young woman

DETECTION OF SENTINEL LYMPH NODES IN PATIENTS WITH THYROID CANCER WITH THE USE OF TOLUIDINE BLUE

Introduction. Treatment of patients with thyroid cancer (TС) with clinically undetected metastases to regional lymph nodes remains an unsolved problem of modern oncology. The search for reliable diagnostic methods, which underlie the decision to perform an adequate lymphadenectomy for TC, is one of the priorities of oncosurgery. The aim of the research: to find an effective method of intraoperative contrasting of sentinel lymph nodes (SLN) in patients with TC using toluidine blue and to evaluate its effectiveness. Methods. A study of 123 patients with TC who underwent surgical treatment using the contrast-visual method in the amount of thyroidectomy with central and bilateral selective cervical lymph node dissection (levels VI; IIA; III; IV). During surgery, a 1% solution of toluidine blue was injected into the tumor using a syringe. Surgical treatment was performed in two stages. At the first stage – thyroidectomy was performed in a block with a central lymphatic collector of the neck (level IV), which included removal of paratracheal, prelaryngeal, parathyroid tissue of the neck. Urgent intraoperative histological examination of thyroid tumor and distant SLN was performed. In the second stage of the operation performed cervical lymph node dissection with removal of fiber IIA; III; IV levels of the neck, with mandatory revision of the level of VB. After the operation, the final histological examination of the removed specimen with the tumor and all lymph nodes was performed. Results. After the application contrasting technique, SLN were found in 120 (97.6%) patients. Their number varied from 2 to 12. These lymph nodes were mainly localized in the central collector of the neck on the side of the primary tumor (central, ipsilateral SLN) in 91 (75.8%) patients. Based on the results of an intraoperative study of SLN, metastases were found in 33 (27.5%) of 120 patients. In most cases (83.3%) SLNs were detected in the central lymphatic collector of the neck (level VI). In 76 (63.3%) patients, staining of the lymph nodes of the III level of the neck (middle ipsilateral jugular lymphatic collector) occurred, in 11 (9.2%) SLNs were found only at levels III, IV and VB of the neck. Very rarely (5.8%), the lymph nodes of the anterior-superior mediastinum were contrasted. Conclusions. The method of contrast visualization of the regional collector in patients with TC using a 1% solution of toluidine blue is a highly informative study that allows to determine the regional lymph nodes affected by metastases and to differentiate the choice of the volume of lymph node dissection in the early stages of tumors. The method is simple to implement, does not involve considerable costs and can be recommended for use in oncology clinics.

Stenting of dominant artery due to symptomatic progression on bilateral vertebral artery dissection: A case report

Stenting of dominant artery due to symptomatic progression on bilateral vertebral artery dissection: A case report

Metastatic Ovarian Tumor of Vulvar Malignant Melanoma in a 43-Year-Old Woman: A Case Report and Literature Review

An ovarian malignant melanoma sometimes occurs from ovarian teratoma. Ovarian metastatic malignant melanoma is extremely rare. We describe a patient in whom vulvar melanoma (previously resected) metastasized to the ovary, making ovarian metastatic malignant melanoma. A 43-year-old Japanese woman was referred to us because of left ovarian tumor. She had undergone resection for malignant melanoma on the right labia minora with inguinal lymph node metastasis (pT1bN1aM0, stage IIIA, FIGO 2008). Eighteen months after this surgery, CT scans revealed left ovarian tumor and swelled pelvic lymph nodes, with a pelvic examination disclosing a left adnexal solid mass, with normal serum CA125 level (21.7 U/mL). Laparotomy revealed a left solid ovarian tumor measuring 4 cm, which was covered with a smooth grayish capsule. The right ovary, uterus, and pelvic cavity appeared normal. Upon sectioning during the surgery, the cross-sectional surface of the left ovary revealed a dark brown solid tumor. Following an intra-operative frozen-section diagnosis as metastatic melanoma, total hysterectomy with bilateral salpingo-oophorectomy and pelvic lymph dissection was performed. Histological examination confirmed the diagnosis as malignant melanoma metastasis to the left ovary and the obturator lymph node: the same laterality (left) as the primary site. The tumor was entirely composed of malignant melanoma cells with no evidence of teratoma. Combined chemotherapy with dabrafenib mesylate and trametinib was planned based on the positive BRAF mutations. This case highlights the importance that physicians should have high index of suspicion for the occurrence of ovarian melanoma metastasis after melanoma surgery. We also made extensive literature review on this issue, of which description may contribute to better understanding of this condition.

Ovary and Uterus, Rare Sites of Metastases from Breast Cancer: A Case Series

Bones, lungs, and liver are frequent sites of metastases of breast cancer. However, female genital tract (ovaries, uterus, etc.) metastases of breast cancer often present a challenge for diagnosis. The distinction between primary and metastasis may be difficult. Immunostaining has a pivotal role in determining the distinction of breast cancer metastases to ovaries and uterus and primary ovarian and uterine cancer. We herein report rare cases of ovarian and uterine metastases in women who have prior carcinoma of the breast and the role of immunohistochemistry in diagnosing these cases. Case 1 highlights a 42-year-old with breast cancer, stage IV who presented with a breast mass and nipple retraction and an enlarging abdominal mass, probably an ovarian new growth, probably malignant by transvaginal sonography. Exploratory laparotomy, peritoneal fluid cytology, total abdominal hysterectomy with bilateral salpingo-oophorectomy, random peritoneal biopsy, bilateral lymph node dissection were done revealing metastatic ovarian cancer probably invasive lobular carcinoma of breast origin. Case 2 reports 42 years old diagnosed with hormone receptor-positive breast cancer stage IV, received 4 cycles of systemic chemotherapy and 20 cycles of radiation therapy of mediastinal mass. On Tamoxifen as a maintenance drug hence ovarian ablation was recommended. Total abdominal hysterectomy with bilateral salpingo-oophorectomy, intraabdominal omentectomy were done with the histopathologic result of metastatic carcinoma with mixed lobular and ductal features probably breast in origin on bilateral ovaries. Case 3 is a 38 y/o with 8 month-history of breast mass with associated pain, diagnosed with invasive ductal carcinoma, right stage IIIB (T4N0M0) after modified radical mastectomy of the right breast. On follow-up, abdominopelvic CT scan done showed multiple intraabdominal and retroperitoneal and pelvic lymphadenopathies probably metastasis. Exploratory laparotomy, drainage of ascitic fluid, infrasonic omentectomy, bilateral salpingo-oophorectomy, peritoneal biopsy were done with histopathologic findings of metastatic poorly differentiated carcinoma, probably ductal carcinoma, bilateral ovaries.

The feasibility and technical strategy of a fascia space priority approach in laparoscopic lateral lymph node dissection for advanced middle and low rectal cancer: a retrospective multicentre study.

IntroductionLaparoscopic lateral lymph node dissection (LLND) is an important treatment for patients with lateral lymph node metastasis.AimTo assess the technical feasibility and investigate the surgical outcomes after LLND using the fascia space priority approach for patients with advanced middle and low rectal cancer.Material and methodsConsecutive patients undergoing laparoscopic LLND using the fascia space priority approach from June 2017 to June 2020 were identified from 12 medical centres in mainland China. Three anatomic fascia spaces were dissected to establish the boundaries of the LLND, and the obturator and internal iliac lymph nodes were excised in an en bloc manner. Retrospective clinical data including patient characteristics, surgical details, and pathology were analysed.ResultsA total of 112 patients were identified. All surgeries were completed laparoscopically with no conversions. The mean operation time was 343.6 ±103.8 min for the entire procedure. The median blood loss was 100 ml (range: 100–700 ml). The median lymph node yield was 6 (range: 1–41), and lymph nodes were positive in 39.3% (44/112) of the patients. Sixteen (14.3%) patients had Clavien-Dindo I–II complications, no Clavien-Dindo III–IV complications were identified. The incidence of complications between the bilateral dissection group and the unilateral dissection group was not statistically different (p = 0.19). The complication rate between the “nCRT” group and the “no nCRT” group was not significantly different (p = 0.62) either. There were no perioperative deaths.ConclusionsLaparoscopic LLND using the fascia space priority approach is feasible and safe for patients with lateral lymph node metastasis.

Combine preoperative estimation of serum thyroglobulin and ACR-thyroid imaging reporting and data system scoring could accurately define malignant thyroid nodules

Background: Evaluation of diagnostic ability of preoperative estimation of serum thyroglobulin (TG) to detect malignant thyroid nodules (TN) in comparison to the American College of Radiology, Thyroid imaging reporting and data system (ACR-TIRADS), fine needle aspiration cytology (FNAC) and intraoperative frozen section (IO-FS).Methods: 34 patients with ACR-TIRADS 2-4 TN were evaluated preoperatively for identification of malignancy and all underwent total thyroidectomy with bilateral neck block dissection if indicated. Results of preoperative investigations were statistically analyzed using the Receiver operating characteristics (ROC) curve analysis as predictors for malignancy in comparison to postoperative paraffin sections.Results: Preoperative serum TG levels had 100% sensitivity and negative predictive value, while ACR-TIRADS scoring had 100% specificity and positive predictive value with accuracy rates of 95.35% and 97.67% for TG and TIRADS, respectively. ROC curve analysis defined preoperative ACR-TIRADS class and serum TG as highly diagnostic than FNAC for defining malignancy with non-significant difference between areas under curve for TIRADS and TG. For cases had intermediate risk of malignancy on TIRADS, IO-FS had missed 3, FNAC missed 4, while serum TG levels were very high in the 13 cases and were defined by ROC curve as the only significant predictor for malignancy.Conclusions: Preoperative estimation of serum TG showed higher diagnostic validity than FNAC, high predictability of cancer and ability to verify the intermediate findings on TIRADS. Combined preoperative TIRADS and TG estimation could accurately discriminate malignant TN with high accuracy and spare the need for preoperative FNAC or IO-FS.